DATE: Sunday, March 9, 1997                 TAG: 9703060014

SECTION: COMMENTARY              PAGE: J4   EDITION: FINAL 

TYPE: Opinion

SOURCE: BY ALBERT L. ROPER II 

                                            LENGTH:   72 lines

SURGERY WARRANTED, BUT REIMBURSERS SAY NO

Dear Kyle,

I enjoyed meeting you in my office. For a 9-month-old boy, you were quite happy and had loads of personality. As your mom remembers, you were referred to me by Dr. Leadem, a board certified pediatrician, for correction of ankyloglossia. That is a mighty big word for such a little boy, so we will call it severe tongue-tie. The tip of your tongue is bound down to your lower gum (you do not have teeth yet) by a band of tissue no longer than the thickness of a penny.

I proposed that we perform a procedure to release your tongue, as you will need proper mobility in your speech development, and the condition could affect your dental development. A few stiches, a brief anesthetic, during an outpatient visit.

Unfortunately, the federal government has authorized your health care to be administered by a large medical conglomerate. The conglomerate's representative, a family practitioner who has never met you, has denied authorization for the procedure. He works for the insurance company. He says you have no problem nursing, so you do not need the procedure.

At any rate, the insurance company has your premium. Its representative says your case ``doesn't meet the guidelines.'' That's funny. I am on the committee that approves ``guidelines,'' and I do not remember seeing or approving any such ``guidelines.''

It has been suggested that I am ``not right for managed care.'' I agree. My responsibility is to a much higher authority, the health and welfare of my patients.

Don't worry if your speech develops poorly; speech therapy may be able to help later. Don't plan to stick out your tongue at your sister. Boys should not whistle at pretty girls, but don't worry: You won't be able to whistle. You cannot lick strained peaches off your lips when you eat, but your Mom can wipe your face until you are older.

Fortunately, it rarely snows here so you will never miss the pleasure of catching a snowflake on your tongue. On the the other hand, neither will you survive the heat by licking ice cream cones.

Since stamps no longer need to be licked, the fact that your tongue will not go past your teeth (when you get teeth) will not make any difference.

I will be glad to perform the procedure without charge, as your future is more important to me than knuckling under to something that I believe is wrong. The pittance paid by your insurance company will not touch the hours I have invested in your ``case'' already. Unfortunately, the costs of anesthesia and the operating room are more than your Mom can afford, and the conglomerate owns the operating room.

Don't worry, Kyle. I am your advocate. I will not accept the Neurenburg-like defense: ``I was just following orders.'' I refuse to accept arbitrary and capricious ``guidelines'' administered by bureaucrats who in the employ of the insurance companies.

I will spend the many hours necessary hours to go through all the boards of appeal. We have strong allies. We can count on the Medical Society of Virginia and the American Academy of Otolaryngology-Head & Neck Surgery. There are mechanisms to involve the state insurance commissioner and possibly the federal government, too, since this insurance is involved with Medicaid.

I have plenty of time. So do you. In fact, I believe you have 19 years and three months to take action (two years past the age of majority). The doctors and executives who say you case doesn't meet the guidelines may be gone then. If not, they will be glad to ``make things right'' one way or another when you are an adult. Please use this letter as my testimony, as I probably will be gone,

Kyle, there are reasonable people around. We will prevail. We will fix your tongue.

I will buy you an ice cream cone.

Sincerely,

Dr. Al MEMO: Dr. Albert L. Roper II is a practicing ear, nose and throat

specialist.

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